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Background: Rhabdomyolysis is severe and acute skeletal muscle damage resulting in sarcolemma disruption. During injury, intracellular muscle contents are released into the plasma. The consequences may cause hypovolemia, electrolyte abnormalities, compartment syndrome, or even acute renal failure and dialysis., Case Report: We present the history of a patient in whom exertional rhabdomyolysis was misdiagnosed. A 20-year-old male police recruit was admitted to a psychiatric hospital because of complaints about black urine and severe thigh pain. Serum creatinine kinase (CK) was significantly elevated at 87,335 U/l. Urinalysis showed brown color and cloudiness. Serum myoglobin was also significantly increased. Aspartate aminotransferase was elevated as was alanine aminotransferase. Immediate intravascular fluid hydration and hospital rest under renal, metabolic, and hematological monitoring was performed., Conclusions: Gymnastic teachers and people at environmental risk of rhabdomyolysis, such as members of the armed forces, police, and supervisors of physical laborers, need to remember the risks of intensive and repetitive exercise. Symptoms such as dark urine, myalgia, and muscle weakness should immediately arouse suspicion of rhabdomyolysis. Especially dark-colored urine should always be investigated for the occurrence of rhabdomyolysis.

Aims: This study investigated whether fluid removal during a hemodialysis (HD) session affects the results of non-invasive pulse volume recording (PVR) on the lower extremities., Methods: The results of PVR by air plethysmography (Portable Vascular Laboratory; BioMedix, USA) were compared with bioelectrical impedance analysis (Nutriguard-M device; Data Input, Germany) of the human body before and after a single HD in 28 anuric patients (10 women; 18 men) aged 33-76 years., Results: Changes in the wave amplitude of the PVR correlated with the changes in the patient's weight during HD. Lower stroke volume at the end of HD due to blood volume withdrawal resulted in PVR reduction at the ankle level. Significant Spearman coefficients were found between extracellular water and PVR amplitude changes (r = 0.7, p < 0.01) as well as between intracellular water and PVR (r = 0.6, p < 0.04)., Conclusions: To avoid falsification connected with hypervolemia and stroke volume change, the most appropriate time for PVR in vascular diagnosing seems to be the period of a few hours after dialysis session., (Copyright 2008 S. Karger AG, Basel.)

Kidney transplantation causes an immune response to non-self antigens called allograft rejection. The response to a kidney allograft can be divided into three phases: recognition of the alloantigen, activation of antigen-specific lymphocytes, and the effector phase of graft rejection. Full T-cell activation requires two distinct signals: one through the TCR and a second costimulatory signal through accessory molecules. These accessory molecules play two important roles. The first is to maintain contact between the T cells and APCs, thus providing time for the TCR to sample the antigen on the APC (ICAM-1/LFA-1). The second role is to cooperate with TCR-initiated signals in T-cell activation. The most important second costimulatory signals influencing T-cell clonal expansion and differentiation are provided by the B7/CD28 family of molecules. In the effector phase of graft rejection, foreign cells are damaged by means of three possible mechanisms: 1) T-cell cytotoxicity, 2) delayed-type hypersensitivity, and 3) antibody-dependent cell-mediated cytotoxicity.

Kidney transplantation causes an immune response to non-self antigens called allograft rejection. The response to a kidney allograft can be divided into three phases: recognition of the alloantigen, activation of antigen-specific lymphocytes, and the effector phase of graft rejection. Allogeneic major histocompatibility complex (MHC) class I and class II molecules elicit a vigorous T-cell response. The alloresponse comprises CD4+ T cells that recognize allogeneic MHC indirectly after processing the molecules into peptide fragments. The majority of alloreactive T cells directly recognize intact allogeneic MHC molecules expressed on foreign cells. The interaction between the TCR of a T cell and the MHC/peptide complex on an antigen-presenting cell (APC) determines the specificity of the immune response. Two distinct signals are required for T-cell activation: one signal through the TCR and a second costimulatory signal through accessory molecules.

Thanks to a precisely regulated response, the immune system works to maintain homeostasis, and one of the significant mechanisms of this regulation is regulatory T cells. This paper presents the latest knowledge concerning the occurrence of natural regulatory T cells of CD4+CD25+ phenotype and their role in the pathogeneses of immune system diseases. Functional and quantitative disorders in this population of cells are found in many diseases which in their course attack the kidney, for instance mixed cryoglobulinemia, rheumatoid arthritis, Sjögren's syndrome, lupus erythematosus, and type 1 diabetes mellitus. The role of T cells and the effectory and regulatory mechanisms dependent on them in the development and progression of glomerulonephritis is presented. The role of regulatory T cells in the development and progression of chronic kidney disease is discussed as well. Qualms whether a decreased number and/or disrupted function of regulatory T cells promote the development of autoimmune diseases or whether they are secondary phenomena are settled by clinical observations in which restoration of the number of the cells prevents further tissue damage. Strengthening or blocking regulatory T-cell functions and obtaining a balance between activation and suppression in the immune system depending on current needs may become the key to the immunotherapy of many diseases. Another problem presented in this paper is the perspective of regulatory T cell therapy; however, attempts to modify their activity and change the number of cells must be carried with the greatest of care because such a procedure may result in dysregulation of the immune system.

The best kind of vascular access in patients with chronic renal failure is the arterio-venous native fistula made of patient's own vessels. Recently it has been shown that morbidity and mortality is lower in patients with native fistula than in patients with permanent catheters or with fistulas made from artificial materials. It is believed that so called ,difficult patients" exist in whom creating permanent vascular access, particularly native fistula might be difficult. The group of "difficult patients" is large and includes mainly diabetics and the elderly. In the paper the principles and causes of difficulties in creation of vascular access are presented. Recent results of our Centre concerning creation of fistulas in diabetics and the elderly are revealed. According to our experiences neither diabetes nor old age don't provide additional difficulties in creation of permanent vascular access.

In the population of hemodialysis patients the risk of ischemic heart disease and morbidity related to it, is considerably higher than in general population. In the group of elderly hemodialysed patients and in patients with diabetes this risk is even higher Additional risk factors of cardiovascular disease are those specific for renal insufficiency, including the presence of arterio-venous fistula, which is believed to be an independent risk factor for cardiovascular disease through the promotion of hyperkinetic circulation. In the study the impact of the arterio-venous fistula on heart function in Doppler USG in the group of 16 elderly hemodialysis patients (aged 79, 4 +/- 5,4), 10 diabetics with type 2 diabetes (aged 63,2 +/- 10,4) and 7 hemodialysis patients younger and without diabetes was examined. In all patients arterio-venous fistula was created on the forearm from native vessels. The following hemodynamic USG parameters of heart function were assessed: ejection fraction (EF), shortening fraction (FS), stroke volume (SV) and cardiac output (CO). We conclude that impact of native arterio-venous fistula created on forearm on circulation in the group of elderly and diabetic patients is of the same magnitude as in the group of younger, non diabetic patients.

Progress in immunosuppressive therapy has improved short-term survival of renal allografts by decreasing the frequency of acute rejections. However, the long-term survival of renal grafts has not improved. Transplanted kidneys are lost in the late period after transplantation as a result of vasculopathy and chronic rejection. Immunological tolerance means the lack of immunological activity towards certain antigens while the response towards others remains correct. The induction of immunological tolerance of donor antigens (transplant tolerance) is examined intensively to work out treatment methods which will allow prevention of chronic allograft rejection. The paper includes an overview of current knowledge on allograft tolerance. Immune response to alloantigens is described and the mechanisms of immunological tolerance induction (including clonal deletion, anergy connected with the microchimerism phenomenon, and active suppression caused by regulatory lymphocytes) are characterized. The role of dendritic cells in the process of inducing and maintaining tolerance is highlighted. Tolerance-inducing strategies in renal transplant recipients and clinically applied evaluation methods are presented. At present, optimizing recipient matching is used to decrease the risk of graft rejection. Hopefully, gene therapy will be possible in the near future. However, before introducing such a procedure into clinical studies, optimal therapy conditions and risk evaluation must be defined in tests on animals.

Patients with end-stage renal disease (ESRD) and coronary heart disease have a very high risk of cardiovascular mortality. We describe results of recent studies on prevention and treatment strategies. Although the outcomes of revascularization methods, i.e. coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI), in ESRD patients are worse than in the general population, CABG and PCI significantly improve survival of the ESRD population. The studies suggest more favorable results with CABG compared with PCI. Patients with a kidney transplant and coronary artery disease (CAD) have better prognosis. In this population, the long-term results of revascularization (CABG and PCI) are comparable. Studies should be focused on optimizing and individualizing revascularization methods, preventing restenosis after PCI, and improving invasive cardiology techniques and anti-aggregation treatments.

Cardiovascular diseases are the major cause of mortality in patients with end-stage renal disease (ESRD) undergoing dialysis. Among ESRD patients the atherosclerotic process progresses more dynamically than in the general population because of exposure to additional, non-traditional risk factors. Diagnosis of coronary artery disease based on history data, physical examination, and additional tests can be difficult due to the coexistence of many disorders and the influence of dialysis treatment. Studies to investigate the pathology of atherosclerosis in patients undergoing dialysis are needed.

This work presents general rules for qualifying patients with end-stage renal failure in the course of diabetic nephropathy for renal replacement therapy by haemodialysis or peritoneal dialysis. Both medical and social considerations conditioning the choice of the dialytic therapy and the most frequent problems characteristic of each method were discussed in the paper. Much attention was focused on the psychological aspect of accepting the disease and the possibilities of emotional disorder in a patient and on the social aspect defining interpersonal relations within patient's family and environment.

The authors expounded present state of knowledge concerning immunosuppressive drugs therapy during pregnancy after kidney transplantation. Pregnancy is uncommon in women with end-stage renal disease treated with dialysis and in most cases it ends with pregnancy failure. Resuming the normal function of the ovaries after kidney transplantation substantially increases the chances of conception and successful pregnancy. The immunosuppression scheme and dosage of drugs used in pregnant women are vital to both the normal course of pregnancy and delivery of a healthy child. Considering the safety of the fetus it is acceptable to use prednisone, azathioprine, cyclosporine and tacrolimus. Due to the necessity to administer immunosuppressive drugs in relatively small doses, an important factor conditioning the normal course of pregnancy is maintaining a 1- or 2-year interval between the kidney transplantation and the conception.

Aim: Patients with autosomal dominant polycystic kidney (ADPKD) present a number of vascular abnormalities, including cerebral aneurysms, heart valve lesions, coarctations of aorta and abdominal aortic aneurysms. The aim of our study was to investigate whether vascular abnormalities that occur in wrist vessels, make native arteriovenous fistula creation difficult in this group of patients., Patients and Methods: The problem was analyzed retrospectively in 783 patients with chronic kidney failure who had had arteriovenous fistula created in our centre in the period between 1991 and 2001. ADPKD was the cause of terminal renal failure in 57 patients (7.3%). These were 31 men and 26 women aged 28 - 69 years (52 +/- 16 years on average)., Results: A difference between left and right radial artery diameters and a narrow radial artery (below 2 mm), unsuitable for fistula creation, occurred in 12% of patients with ADPKD and in 0.38% of other patients. Instead of a cephalic vein in the typical place, a few small vessels were present in 14% of patients with ADPKD and in 2.17% of patients with other causes of renal failure., Conclusion: Our experience shows a higher incidence of wrist vascular abnormalities in patients with ADPKD. This decreases the possibility of wrist native arteriovenous fistula creation in this group of patients.

This paper deals with the current genetic knowledge about autosomal dominant polycystic kidney disease (ADPKD). A short history of the mapping of the PKD1 and PKD2 genes, the types of mutations in these genes and methods of their detection are described. The main research trends involve mutations in PKD genes and the relation between the type of mutation and clinical features of the disease, the role of polycystins in the pathogenesis of ADPKD, and attempts to assess the influence of environmental factors on the progression of the disease. The second-hit model and the role of modifying genes in the pathogenesis of the disease are also discussed. The clinical manifestation of ADPKD, especially the risk factors of unfavorable progression and extrarenal manifestation of the disease, are presented, with particular emphasis on changes in the circulatory and nervous systems. Therapeutic implications as well as the relations between autosomal polycystic kidney disease and the recently described autosomal dominant polycystic liver disease are also discussed.

Introduction: Patients' perception of health is an important outcome measure in the assessment of influence of chronic disease and received treatment. The purpose of this study was: 1) to investigate the relation between selected demographic and clinical characteristics and Health-related Quality of Life (HRQoL) scores in patients with end-stage renal disease (ESRD) who receive dialysis, 2) to compare HRQoL in dialysis patients with their peers from the control group, 3) to evaluate the usefulness of SF-36 questionnaire., Material and Methods: We evaluated Health-Realated Quality of Life (HRQoL) of dialysis patients by the Polish version of the Short Form 36 Items Health Survey (SF-36). The SF-36 consists of eight scales: physical functioning (PF), social functioning (SF), role limitation attributable to physical problems (RP), role limitation attributable to emotional problems (RE), mental health (MH), vitality (VT), bodily pain (BP) and general health perception (GH). This study included 97 patients (44 men and 53 women), aged 28-86 years (mean age: 57.2) treated with HD (n = 77) and CAPD (n = 20) for 3-245 months (mean: 61 months). We compared the results with the data obtained from 217 healthy control subjects (105 men and 112 women), aged 20-92 years (mean age 51.1). The patients were divided into four age-groups and compared with the appropriate groups of controls., Results: The perception of health of dialysis patients was worse than that of controls. We have found, that in the group aged over 65 years patients' scores were quite close to those of the control population. Our results show the following patient-connected factors to be independently associated with quality of life (QoL): age, sex, occupation, level of education, family situation and comorbidities. On average, females reported lower scores; the impact of ageing was more evident in physical scales., Conclusions: 1) age, sex, occupation, level of education, family situation as well as comorbidities are independent factors of HRQoL, 2) subjective QoL of elderly patients seems acceptable in comparison with healthier peers, 3) the SF-36 questionnaire is applicable in dialysis patients and SF-36 scores are related to important clinical aspects.

Background: It is commonly known that the best type of vascular access for chronic hemodialysis, defined as the one with the lowest number of complications and longest use, is the primary (Brescia-Cimino) radiocephalic fistula. One reason for the impossibility of its creation is that the vein vessel on the forearm is located too deeply, which is primarily caused by the patients' obesity., Methods: In 24 obese patients the superficialization procedure of the venous part of fistula under the skin was performed., Results: In 23 patients of this group, an easy and uncomplicated fistula puncturing was achieved. One patient had the complication of fistula clotting., Conclusion: Subcutaneous transposition of the arterialized median antebrachial vein is a simple and effective method of an adequate distal native fistula creation in patients with deeply located forearm veins.

Cannulation of the femoral vein is the safest method of acute vascular access. It is recommended the removal of the femoral catheter after 72 h. The trial was undertaken, if it is possible a safe prolonged use of the femoral cannulation. The observations were performed in 70 patients (31 F, 39 M, age 3-70 years) with acute and chronic renal failure (RF). The femoral catheter was left in place for the period from 7 to 104 days, mean 21 days. None complications occurred in the group of 16 patients in whose the cannula was left up to 14 days. Bt duration of the cannulation above 15 days (54 patients) exist site infections appeared in 10 patients, catheter thrombosis in 12 patients and fiber in 6 patients (all with the catheter in place above 21 days). Noteworthly chronic RF patients were dialysed mostly on the ambulatory basis. Femoral catheter can be left safely in place for 14 days.

In 19 patients aged 19 to 45 years on long-term dialysis treatment during 12.6 +/- 18.2 months the concentrations of Rb and Cs were determined by atomic spectrometry in whole blood before and behind the dialyser at the beginning and end of dialysis. At the same time the concentrations of these elements were determined in the dialysing fluid. In all patients the velocity of conduction in the motor fibres in the upper and lower extremities was determined before and after dialysis. Damage to the peripheral neurons was demonstrated in the lower extremities mainly in 79% of cases. Increased velocity of motor conduction in at least one nerve related directly proportionally to the Cs concentration of the serum was demonstrated in 56-70% of the patients after one dialysis.